lactateuseindem1-140212211922-phpapp01

7/27/2019 lactateuseindem1-140212211922-phpapp01

1/19

P R A N E E L K U M A RB U N D A B E R G E M E R G E N C Y D E P A R T M E N T

LACTATE USE IN DEM


2/19

WHY USE LACTATE

Relative lack of sensitivity of clinical signs to predictthe presence or absence of organ injury or tissuehypo perfusion

Lack of standardization in clinical examinationtechnique


3/19

SERUM LACTATE


4/19


5/19

DIAGNOSTIC BIOMKER


6/19

DIAGNOSTIC BIOMARKER

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsisand septic shock. N Engl J Med 2001;345(19):1368

77.

Elevated lactate levels in severe sepsis or septicshock before resuscitation coincided with low

central venous oxygen saturation (Scvo2)

Reflective of tissue hypoxia


7/19

SCREENING


8/19

SCREENING

Occult shock

- Identify patients with underlying tissue hypoperfusion before the development of clinical

findings- Depends on patient pretest probability and

likelihood ratio


9/19

PROGNOSTIC


10/19

PROGNOSTIC

Shapiro NI,Howell MD, Talmor D, et al. Serumlactate as a predictor of mortality in emergency

department patients with infection. Ann Emerg Med2005;45(5):5248;

1278 adult patient


11/19

PROGNOSTIC


12/19

PROGNOSTIC

Scott S, Antonaglia V, Guiotto G, et al. Two-hourlactate clearance predicts negative outcome in

patients with cardiorespiratory insufficiency. CritCare Res Pract 2010;2010. Article ID 917053.


13/19

PROGNOSTIC

Arterial lactate levels were measured on ED arrivaland at 1,2,6 and 25 hours later

The predictive value of 2-hour lactate clearance

was evaluated for negative outcomes defined ashospital mortality or need for endotrachealintubation versus positive outcomes defined asdischarge or transfer to a general medical ward


14/19

PROGNOSTIC

2 hour lactate clearance of less than 15% was astrong predictor of negative outcome

P < 0.001

Sensitivity of 86%,Specificity of 91%,PPV 80% 2 hour lactate clearance proved more accurate

than baseline lactate levels, the shock index,MAPand the base excess

2hour lactate level were more reliable even thebaseine lactate level was only mildly elevated at3mmol/l


15/19

TOOLS FOR MONITORING

INTERVENTION


16/19

TOOLS FOR MONITORING

INTERVENTION

Jones AE, Shapiro NI, Trzeciak S, et al. Lactateclearance vs central venous oxygen saturation as

goals of early sepsis therapy. JAMA 2010;303(8):


17/19

300 patients with severe sepsis were randomlyassigned to one of the 2 resuscitation protocols inthe first 6hours

1st

resuscitate to normalise CVP, MAP and SvCO2of at least 70%( surviving sepsis campaign guideline)

2ndCVP,MAP and lactate clearance of at least10%

Primary measure- in hospital mortality rate


18/19

Outcome- patients with septic shock, who weretreated to normalize CVP and MAP, additionalmanagement to normalize lactate clearance

compared with management to normalize ScvO2did not result in significantly different in-hospitalmortality.


19/19

lactateuseindem1-140212211922-phpapp01

Documents